Bloom syndrome: an oral potentially malignant disorders aiding in malignancy vigour
Authors: Manjusha Muralidharan, Saravanan Muthupandian, Tsehaye A. Dejene
Journal: International Journal of Surgery (2023)

Dear Editor, Every day, millions of new cancer cases are recorded, suggesting that the disease is increasingly threatening people all over the world. This deadly disease is projected to increase in prevalence by a factor of five. The Knudson two-hit hypothesis proposes that the inherent mutation serves as the first hit to a gene, with a subsequent event serving as the second hit that causes cancer to develop. Many cases begin with the development of precancerous diseases. All clinical manifestations that carry the risk of cancer, including syndromes linked with a higher-than-normal risk of malignant transformation, are collectively referred to as 'oral potentially malignant disorders'1. Bloom syndrome (BS), often called Bloom-Torre-Machacek syndrome after the researchers who discovered it, is one such oral potentially malignant disorders. People of European Jewish descent are adversely impacted from BS. The primary clinical hallmark of BS is short stature, and it is transmitted in an extremely rare autosomal recessive pattern2. The presence of a sun-sensitive, erythematous lesion on the face, an abundance of well-demarcated hyperpigmented and hypopigmented skin lesions anywhere on the body, and an increase in the number of bacterial infections related to immunodeficiency are all helpful diagnostic markers. Cancer, chronic lung disease and diabetes are some of the severe consequences of BS. Cancers of the normal forms and locations appear at unusually high and early rates. Many of the symptoms of BS result from the hypermutability of the cells that comprise the condition. Patients with BS are prone to the same types of cancers as the general population, but they tend to manifest considerably earlier in life. The current BS population has a mean age of 18 years (range: 4–37 years). In the BS population, cancer often presents at age 20 years (range: 4–44 years), with a proportion of 1:40 men to every woman, making men more susceptible to BS. Ashkenazi Jews, non-Jewish Semites, Japanese, Western European Christians and African-Americans are few of the ethnic groups and races that have been shown to have BS. More than one in every 120 Israeli Ashkenazi's is a carrier of at least one allele of the heritable disease. Cytogenetic evidence of a signature kind of chromosomal instability confirms the clinical diagnosis3. Cancer was the cause of death for every person with BS who made it past childhood. Tongue and laryngeal carcinoma were among the primary lesions found in five of the first 103 BS patients. There were smokers and nonsmokers, Jews and non-Jews and people of all ages (from 26 to 34 years) from the USA, Canada and Australia who participated in the study. The male population was four times that of the female population. The most striking distinction from non-BS patients was the young age of onset of the disease, as the presenting symptoms and tumour histology were identical. Two BS patients with second primary tumours showed the importance of careful postoperative monitoring for the development of secondary tumours anywhere in the body, not just the head and neck. Having a computed tomography scan periodically and having regular physical examinations are both necessary4. Researchers studied the frequency of micronuclei in exfoliated epithelial cells in two small human populations: those homozygous and heterozygous for the Bloom syndrome gene (BML). They analysed 11 obligate heterozygotes (BML/+), including the parents of affected individuals, and eight homozygotes (BML/BML) for the BS gene, that is, people with the clinical condition5. Oral and urinary exfoliated cells were collected. Statistically substantial increases in the frequency of cells with micronuclei were seen in cells from both sites in BML/BML persons compared with that in BML/+ (P<0.001) and in a control group, showing that chromosome instability occurs in vivo in BS. However, there was no statistically significant difference in the frequency of micronuclei between BML/+ and the control group at either site. In light of the results of this study and comparable earlier studies of populations at risk for malignancy not due to inherited susceptibility but due to interaction to an environmental carcinogen, it seems likely that the exfoliated cell micronucleus test can identify people whose somatic genetic material has been disrupted in a way that generates chromosome breakage and rearrangement5. Cancer is more likely to develop in people with BS at a younger age. Head and neck cancers account for 18% of all neoplasms found in BS patients, with most cases appearing in patients' 30s and 40s. The head and neck cancer rate has tripled in the last few decades, which may indicate a genetic vulnerability to the disease. Chromosomal analysis is the gold standard for diagnosing BS. When it comes to head and neck cancer, individuals with BS and those without have the same surgical options. However, because of the higher risk of a second primary tumour developing, postoperative monitoring must be considerably more stringent in the BS patient. As with many other extremely rare genetic diseases, the entire scope of health effects for people with BS is not well understood. The BS Registry aims to address this issue by the systematic investigation of issues like immunosuppression, lung complications, cognitive decline and cancer pathogenesis and treatment. The tiny number of heterozygotes in any group makes it difficult to adequately power evaluations of risk, however, research into health issues among heterozygotes, especially cancer risk, is a topic for further exploration. To further understand how BML may contribute to the aetiology of cancers in those who are neither affected with BS nor heterozygous for BML pathogenic mutations, research into the genomic abnormalities of tumours arising in people with BS is urgently needed. Although finding medicines that can restore some function of the BML protein is the ultimate objective, none have been found yet6. Newborns and infants with BS need to have their caloric intake and nutritional status closely monitored, and they should receive aggressive treatment for gastroesophageal reflux if it is present. The BS community recommends that parents and educators treat children as they would any other child, regardless of their physical stature. Diabetes mellitus care is standard procedure. Standard cancer treatment protocols must be adjusted, that is, dosages and duration must be lowered, for patients with hypersensitivity to DNA-damaging agents and ionizing radiation. Colon cancer screening begins at a much earlier age and is performed more frequently than average, and surveillance includes reviewing unexplained signs and symptoms as potential signals of malignancy. Keep your face out of the sun7. In the meanwhile, it is crucial for parents and doctors to be aware of the unique health issues faced by people with BS and to take swift action at the first sign of trouble. By paying close attention to these health monitoring metrics, we may perhaps standardize assessment of the patient, which will aid in preventive medicine, diagnosis and treatment and improved healthcare outcomes overall. Ethical approval Not applicable. Sources of funding None. Authors' contribution M.M.: investigation, data collection, visualization, writing– original draft preparation. S.M. and T.A.D.: conceptualization, writing – reviewing and editing and supervision. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) Not applicable. Guarantor Tsehaye A. Dejene.